3: History of CHWs in South Africa
Community health workers have been present in South Africa since the first CHW programmes were initiated in the 1920s. The 1997 White Paper on the Transformation of the Health Sector regarded CHWs as separate from primary healthcare teams and did not advocate the incorporation of CHWs into the public service. But when the Health Minister and Health MECs went to Brazil in 2010, they returned with a vision of a wide-reaching CHW cadre integrated into the healthcare system. This led to the National Health Council mandating the establishment of Ward-Based Primary Health Care Outreach Teams (WBPHCOTs) in 2011, and the release by the National Department of Health of the Provincial Guidelines for the Implementation of the Three Streams of PHC Reengineering. The National Department of Health (NDoH) declared ‛seven key foundations’ to its 2012 Human Resources for Health Strategy. The first was the employment and training of a ‛large workforce’ of CHWs. The Department proclaimed that CHWs are central to its strategy and that standardisation of their employment is necessary. The HRH Strategy suggests that CHWs be consolidated into one cadre that will predominantly focus on maternal, child and women’s health plus basic household and community hygiene. 
Unfortunately, it has taken time to move from this vision to implementation. The (still draft) Municipal WBPHCOT Policy Framework and Strategy April 2015 lays out the NDoH’s plans for the CHW programme and will be referred to throughout this article. The draft Investment Case for Ward-Based Primary Health Care Outreach Teams (‛Investment Case’) appears to refine some of the planning from the WBPHCOT Policy and proposes a programme design. That is as far as we have progressed from a policy perspective.
In reality, CHWs and WBPHCOTs already exist. In 2011 there were approximately 72,000 CHWs in South Africa, but this number seems to be a combination of HIV counsellors and health promoters in clinics, CHWs and HBCs. In September 2015 there were 2,965 WBPHCOTs that had been formed in the country but only 59 percent of these were reporting their activities, casting doubt on whether the teams are operational.
CHW programmes differ significantly from province to province and, while few CHWs are treated well, in some provinces the treatment of CHWs is particularly reprehensible. In the Free State, more than 100 CHWs were arrested during a night vigil for protesting their dismissal following a requirement to re-apply for their jobs. In Gauteng, the Department of Health has appointed a payroll management company to be the employer of CHWs to avoid having to pay them as public employees. The following table (chw-per-province) gives an idea of the differences in the provincial programmes. The information was based on an article in the Mail & Guardian and was updated through conversations with CHWs in each province:
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 White paper on Transformation of the Health System in South Africa 1997, p36.
 Human Resources for Health South Africa, HRH Strategy for the Health Sector: 2012/13 – 2016/17, p66.
 Department of Health, 2011. CHW Audit Report. Tshwane: Department of Health (in Draft Investment Case for Ward-Based Primary Health Care Outreach Teams, p41)
 Draft Investment Case for Ward-Based Primary Health Care Outreach Teams, p42.
 M Malan ‛Community healthworkers shafted by SA’s policy shambles’, 12 September 2014. Accessible at: http://bhekisisa.org/article/2014-09-11-community-healthworkers-shafted-by-sas-policy-shambles.
 Thank you to Thuthukile Mbata, researcher at SECTION27, for developing the relationships and making the numerous calls required to update this table. We cannot be certain that the table is accurate but it reflects the best available information at this time.